As a Medicare agent, you strive to educate your clients, helping them evaluate their needs and understand their options when choosing a Medicare plan. You play a significant role in helping them understand Medicare’s five-star-rating system and weighing the importance of the ratings when selecting a plan.

Why the Star Ratings Matter

CMS created the five-star-rating system to evaluate Medicare Advantage (MA) and Part D plans across a number of common measures. Medicare releases the ratings every fall, prior to AEP, to help enrollees compare how plans perform and make it easier for them to find a plan they will be satisfied with.

The 5-star rating of “Excellent” indicates a plan has achieved high scores for customer satisfaction and providing access to needed medical care. Consistently maintaining high scores year after year indicates a plan is stable and well managed.

You may have noticed there are fewer 5-star plans this year. In 2023, CMS reports that approximately 51% of MA plans with prescription drug coverage earned 4 stars or higher, but only 11% of plans received a 5-star rating. The lower ratings were anticipated – they are due to the end of some COVID-19 provisions that were put in place to protect plans against factors out of their control. Therefore, these lower ratings do not necessarily indicate a drop in quality. About 40% of plans received an “Above Average” rating of 4 or 4.5 stars.

CMS considers plans that receive a 3-star rating or less for three consecutive years to be low performing. It flags them until they improve. CMS notifies enrollees in these plans and are gives them a special enrollment period to change plans if they want to. Plans with no rating are too new to have enough data to accurately score them.

A 5-Star Plan Is Not Always the Right Choice

Star ratings are good place to start when comparing plans, but every plan is different. You need to help your clients dig a little deeper to make sure they select plans that are best for them. In addition to the star ratings, your clients should consider:

  • Affordability – What are the out-of-pocket costs, such as premiums, copays, etc.?
  • Networks – Are their doctors, specialists, and preferred hospitals in the plan’s network?
  • Specific condition or treatment – If your clients have chronic diseases or conditions for which they receive regular treatment, make sure they know what coverage the plan will provide.
  • Prescriptions – Are clients’ drugs on the plan’s formulary and will there be out-of-pocket costs? Are their preferred pharmacies in the network? Does the plan offer mail order or require mail order? Your clients might have strong preferences about this.
  • HMO or PPO – Do your clients want the option to see healthcare providers outside the HMO network?
  • Additional benefits – Do they want dental, vision, or hearing benefits or health and wellness benefits, such as gym memberships? CMS rewards 4- and 5-star plans with financial bonuses, leading these higher-rated plans to offer more ancillary benefits.

You can also reassure your clients that if their situation changes – or they are unhappy with their plan choice – they can take advantage of a 5-Star Special Enrollment period, which allows them to switch to a 5-star plan in their area, including if they are currently in a 5-star plan. They can use this enrollment period once each year from December 8 to November 30.

Finding the Right Plan

In 2023, there are 385 Medicare Advantage plans available to residents in the state of Texas. Medicare’s plan finder can be a helpful tool to narrow down the search for available plans by ZIP code, but it still a lot of information for your clients to process. You are the best resource for helping your clients navigate the many plan choices.

Just as you are here to support your clients, PTT Financial is here to support you. Contact us today.